1. A messy on call

2. Mr James Age 48 Works as head lad in racing Vomited Seen at home and is drowsy but also noted that he has some coffee grounds in his vomit

3. Questions What does the story suggest? What might have caused this? Can you think of possible causes?

4. Admitted to hospital Seen in Accident department Examination Slightly yellow Dupytren’s contracture Spider naevi Abdomen – looks bloated Tip of spleen is felt

5. Questions What are the causes of the clinical signs? Why is his spleen enlarged?

6. Questions What is portal hypertension and what are the effects? How can you tell clinically

9. Sudden deterioration Collapses Low blood pressure Very drowsy Passes very smelly and black stools

10. Questions What is this called? Why has he collapsed?

11. Then Massive vomit 2 litres of bright red fresh blood BP now just palpable Carotid pulse 120 Cannot feel radial pulse Sweating

12. Questions What might have happened now? What would you need to do to help him? What investigations would you arrange in the emergency department? What test might he need now?

17. Oliguria What does this mean? Why does this occur? What is the risk if this is not treated?

18. Shock What do we mean by shock? What are the main types of shock?

19. WHAT IS SHOCK? Inadequate Tissue Perfusion

20. Symptoms of Shock Anxiety /Nervousness Dizziness Weakness Faintness Nausea & Vomiting Thirst Confusion Decreased UO Hx of Trauma / other illness Vomiting & Diarrhoea Chest Pain Fevers / Rigors SOB General SymptomsSpecific Symptoms

21. Signs of Shock Pale Cold & Clammy Sweating Cyanosis Tachycardia Tachypnoea Confused / Agitated Unconscious Hypotensive Stridor / SOB

22. Circulatory Homeostasis BP = CO X PVR CO – Cardiac Output PVR – Peripheral Vascular resistance Tissue perfusion is driven by blood pressure

23. What makes up blood volume Plasma RBCs WBCs Platelets

24. What Alters Blood Volume? Haemorrhage Plasma Loss Redistribution of Extracellular Volume

25. Heart Rate Heart rate increases as a compensatory response to Shock Rarely you get High Output failure Heart rate too fast to allow adequate refilling of heart between beats

26. Peripheral Vascular Resistance PVR regulated by ARTERIOLAR tone. Dilatation opens Arteriovenous beds & increases volume of circulatory system

27. What Alters PVR? Circulation cytokines & Inflammatory mediators (e.g. Histamine) Endotoxins Drugs (e.g. Nitrates)

29. Types of Shock Hypovolaemic Cardiogenic Redistributive

30. Hypovolaemic Volume Loss Blood loss -Haemorrhage Plasma Loss-Burns / Pancreatitis ECF Loss- V&D

31. Cardiogenic Pump Failure May be due to inability of heart to Contact Inability of heart to pump blood

32. Redistributive Decreased Peripheral Vascular Resistance Septic Shock Spinal / Neurogenic Shock ANAPHYLACTIC shock

33. Questions